A Public Health
Approach to
Children’s
Mental Health
A Conceptual
Framework
Authors
Jon Miles, PhD
Searchlight Consulting LLC
Rachele C. Espiritu, PhD
Neal M. Horen, PhD
Joyce Sebian, MS Ed
Elizabeth Waetzig, JD
National Technical Assistance
Center for Children’s Mental Health
Georgetown University Center for
Child and Human Development
A Public Health
Approach to
Children’s
Mental Health
A Conceptual
Framework
Authors
Jon Miles, PhD
Searchlight Consulting LLC
Rachele C. Espiritu, PhD
Neal M. Horen, PhD
Joyce Sebian, MS Ed
Elizabeth Waetzig, JD
National Technical Assistance

A Vision for Children and Communities 1
A New Framework
3
Background
5
Children’s Mental Health Problems
5
The Evolution of Children’s Mental Health Care
7
Positive Mental Health as Distinct from Mental Health Problems
9
Shaping Environments and Skills to Optimize Children’s Mental Health
10
Children’s Mental Health Partnerships
11
Public Health Approach
12
“Surely the Time is Right”
13
Challenges to Overcome
15
CHAPTER 2: Laying the Foundation: Key Terms and Concepts 17
Key Terms and Concepts 18
Outcomes and Indicators Language
18
Intervention Language
25
Other Public Health Language
29
Summary

Promoting and Preventing
55
Determinants
56
Process/Action Steps
58
Weaving the Concepts of a Public Health Approach Together
60
Summary
60
CHAPTER 5: Comprehensive Framework 61
A Conceptual Framework 61
Values
62
Guiding Principles
62
Public Health Process: Action Steps
63
Intervening/Intervention
63
A New Model for Intervening
64
Starting with Mental Health Problems and Adding Positive Mental Health
66
Putting it All Together
68
Linking the New Model to Other Terms
70
Attending to Developmental Issues
73

95
Sustainability
96
iv
A Public Health Approach to Children’s Mental Health:A Conceptual Framework
TABLE OF CONTENTS
Part B.How to Get the Work Started
Convening—Building a Coalition
97
Leadership
97
Form a Powerful Guiding Coalition
98
Guiding the Work—Creating a Plan
100
Developing a Shared Vision
100
Developing and Evaluating a Plan
101
Sustaining the Work—Assembling Resources
103
Infrastructure
103
Facilitation
103
Summary
104
Conclusion 105
Appendix: Evolution of “Intervening” in Mental Health 107
References 113

Figure A.2 The Mental Health Intervention Spectrum for Mental Disorders
108
Figure A.3 The Australian Fan Adaptation 110
Figure A.4 2009 IOM Mental Health Intervention Spectrum
111
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A Public Health Approach to Children’s Mental Health:A Conceptual Framework
TABLE OF CONTENTS
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Appreciation goes to a distinguished group of people at the Substance
Abuse and Mental Health Services Administration (SAMHSA). These
professionals contributed leadership, inspiration, recommendations,
editing, information and a depth of knowledge throughout the process of
writing this document.
Many individuals at SAMHSA’s Center for Mental Health Services
(CMHS) were instrumental to the completion of this important conceptual
document. Special appreciation goes to Gary Blau, Ph.D. Branch Chief of
the Child Adolescent and Family Branch, Division of Service and Systems
Improvement (DSSI) and Susan Keys, Ph.D., Executive Director at Inspire
USA Foundation and former Branch Chief within CMHS’s Division of
Prevention, Traumatic Stress and Special Programs (DPTSSP). Their
leadership, vision, collaboration, and commitment guided this work to
completion. Others from within the DPTSSP who made important
contributions include: Division Director, Anne Mathews-Younes, Ed. D.;
Captain O’Neal Walker, Ph.D., USPHS, Branch Chief of the Mental Health
Promotion Branch; Captain Maria Dinger, USPHS M.S., R.N. Branch
Chief for the Suicide Prevention Branch; Michelle Bechard, Public Health
Advisor; Jennifer A. Oppenheim Psy.D.; and Gail Ritchie M.S.W., LCSW-
C. Important contributions from within the DSSI came from Fran
Randolph, Director of DSSI; Michele Herman, Public Health Analyst; and

In addition to the SAMHSA partners and Georgetown faculty acknowledged above, outside
experts who contributed significant time and insight included Patricia Mrazek Ph.D., M.S.W.,
Committee on Prevention of Mental Disorders, Institute of Medicine; Paula F. Nickelson,
M.Ed., Missouri Department of Health and Senior Services; Robert Friedman Ph.D.,
University of South Florida; Marie D’Amico, Health Policy Specialist, Vermont Child Health
Improvement Program (VCHIP); David Osher Ph.D., Vice President, American Institutes for
Research; Conni Wells, Florida Institute for Family Involvement; Sandra Spencer BA, from
the Federation of Families for Children’s Mental Health.; Cathy Ciano, Parent Support
Network of Rhode Island; Jessica Snell-Johns, Ph.D., Director, Promoting Positive Change,
LLC; and representatives from the Washington State Board of Health.
Hundreds of other people, including youth representatives, technical assistance providers,
association leaders, state, territorial, and tribal leaders, and other national partners, made
meaningful contributions by participating in discussions, listening sessions, and written
reviews that helped shape ideas and bring clarity to the document.
While the final document could not incorporate all of the suggestions that were received, all
input was valued and painstakingly considered. The thorough and thoughtful comments
contributed greatly to helping this document meet the expectations that were envisioned for
it. Through the efforts of the people listed above, as well as others whose devoted work has
created the need for the conceptual framework presented herein, it is hoped that this
monograph will a step forward in the important work of enhancing the health and well-being
of our nation’s children and families.
Additionally, the authors want to express their indebtedness and appreciation to the families
and loved one’s who lent their support, patience, and encouragement to the process of
developing this document.
Finally, recognition and gratitude goes to many across the country whose tireless work and
contributions have led to the point where a public health approach to children’s mental
health can be envisioned and achieved.
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A Public Health Approach to Children’s Mental Health:A Conceptual Framework
ACKNOWLEDGMENTS

health entities. This information gathering process was followed by
integration of the information gathered and extensive discussion about
how to best summarize a public health approach to a non-public health
audience, especially as it applies to children’s mental health. Drafts of the
monograph were reviewed by experts in the fields of academia, public
policy, public health, family advocacy, and children’s mental health care.
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A Public Health Approach to Children’s Mental Health:A Conceptual Framework
Foreword
This monograph represents the culmination of efforts to develop consensus around the
central ideas of the conceptual framework. Very early on, it was recognized that
implementing a public health approach to children’s mental health will require three
significant system changes, and that the conceptual framework must ultimately facilitate
movement toward those changes. Specifically, successful implementation requires:
1. The children’s mental health care system to incorporate public health concepts in its
approach to children’s mental health,
2. the public health system to place a greater emphasis on children’s mental health, and
3. other child-serving systems and sectors to identify themselves as partners in a
comprehensive and coordinated children’s mental health system.
Many of the individual ideas that make up the conceptual framework are not new; however,
the new framework represents the first time that public health concepts have been integrated in
this fashion to create a comprehensive and coordinated approach to children’s mental health.
The Intended Audience
This monograph is written for a broad range of leaders who have a role in bringing about
change in their system(s) or organizations and influencing children’s mental health and well-
being. These leaders may be in federal, state, local program, or policy roles. They may be
state, tribal, or regional capacity builders, community providers or volunteers, or consumers
or family members. They may be part of systems or sectors that impact the well-being of
children, including children’s mental health care, public health, juvenile justice, education,
maternal and child health, physical health care, early care/education, child welfare, housing,

new approach to children’s mental health in the United States. Belief in the
need for a new approach is fueled by concern about overburdened health
care systems, high costs, and fragmented approaches to children’s mental
health. At the same time, hope for a new approach is inspired by
successful examples of public health efforts in the area of children’s
physical health, increased recognition of the positive impact of System of
Care values, and greater understanding of the ways healthy environments
can enhance children’s development.
Public health principles suggest that the new approach should focus on a)
reducing mental health problems among children for whom a problem has
been identified and b) helping all children optimize their mental health.
Doing so can improve children’s overall health, competence, and later
functioning and life satisfaction. Strengthening children in this way can
also reduce the burden on an overtaxed mental health care system while
simultaneously improving society’s potential for academic success,
economic well-being, productivity, competitiveness in the global market,
ability to protect the nation’s security, and quality of life.
This monograph advances an approach to children’s mental health that
applies public health concepts to efforts that support children’s mental
health and development. The approach is presented in a conceptual
framework comprised of four major elements: values that underlie the
entire effort, guiding principles that steer the work, a process that consists
of three core public health action steps/functions, and a new model of
intervening that provides the range of intervention activities required to
implement a comprehensive approach. The range of intervention activities
includes promoting positive mental health, preventing mental health
problems, treating mental health problems, and reclaiming optimal health
while addressing a mental health problem.
xiii
A Public Health Approach to Children’s Mental Health:A Conceptual Framework

Mental health of a community: the collective well-being of a community,as indicated by
the aggregated well-being of the members of the community and community characteristics
that are indicative of well-being.
Intervention/intervene/intervening: any effort that attempts to change a current
situation with an individual,group,subpopulation,or population.
Early Intervening: intervening prior to or in the early stages of a mental health problem.
Early Childhood Intervening: intervening with young children to identify developmental
delays and provide services that optimize positive mental health and minimize mental
health problems.
Group, Population, Community: a unified body of individuals that share a common
geographical area,a common social,religious,or cultural background,or a common defining
characteristic (interest,aim, occupation, geographic location).
Table E.1 Summary of Key Terms and How the Terms Are Used in This Document
An Overview of Public Health
Over the past century, anti-smoking campaigns, fluoridated drinking water, nutrition
guidelines, and seat belt laws, are just some of the achievements attributed to the public
health approach. Nevertheless there are multiple perspectives on what constitutes a public
health approach. When distilling the most widely used models, four key public health
concepts emerge that can be readily applied to children’s mental health:
Population Focus: Public health thinks about, intervenes with, and measures the health of the
entire population and uses public policy as a central tool for intervention.
Promoting and Preventing: In public health, the focus includes preventing problems before they
occur by addressing sources of those problems, as well as identifying and promoting
conditions that support optimal health.
Determinants of Health: Interventions in public health work by addressing determinants of
health. Determinants are factors that contribute to the good and bad health of a population.
Malleable factors that are part of the social, economic, physical, or geographical environment
can be influenced by policies and programs.
Process/Action Steps: A public health approach requires implementation of a series of action
steps. In most widely recognized health modesl, these action steps are the three core functions

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Figure E.1 A Conceptual Framework for a Public Health Approach to Children’s Mental Health
xvii
A Public Health Approach to Children’s Mental Health:A Conceptual Framework
The guiding principles infuse the central public health concepts and other key ideas
throughout the entire framework. They include:
• Taking a population focus, which requires an emphasis on the mental health of all children.
Data need to be gathered at population levels to drive decisions about interventions and to
ensure they are implemented and sustained effectively for entire populations.
• Placing greater emphasis on creating environments that promote and support optimal
mental health and on developing skills that enhance resilience.
• Balancing the focus on children’s mental health problems with a focus on children’s
“positive” mental health—increasing our measurement of positive mental health and
striving to optimize positive mental health for every child.
• Working collaboratively across a broad range of systems and sectors, from the child mental
health care system to the public health system to all the other settings and structures that
impact children’s well-being.
• Adapting the implementation to local contexts—taking local needs and strengths into
consideration when implementing the framework.
The process/action steps represented by the blue, green, and red circles in the conceptual
framework (Figure E.1) are based on the three core functions of the public health wheel
described by the Institute of Medicine and presented by the Department of Health and Human
Services
2,3
(see Figure 3.2 in Chapter 3). The first action step, assessing, is centered on the idea
that data are needed to drive decisions about how to strengthen children’s mental health from
a population perspective. In particular, data need to be gathered and analyzed about children’s
mental health and the factors that affect it to generate understanding of how to influence
positive aspects of mental health and mental health problems at the population level.

…is to intervene…
Treat
…is to intervene…
Re/Claim
…is to intervene…
•to optimize positive mental
health by addressing
determinants* of positive
mental health
•to reduce mental health
problems by addressing
determinants of mental
health problems
•to diminish or end the
effects of an identified
mental health problem
•to optimize positive mental
health while taking into
consideration an identified
mental health problem
• before a specific mental
health problem has been
identified in the individual,
group,or population
of focus
• before a specific mental
health problem has been
identified in the individual,
group,or population
of focus

A Public Health Approach to Children’s Mental Health:A Conceptual Framework
While many interventions fit in more than one category, this new model for intervening
provides guidance about the full array of mental health interventions that are needed to serve
all children. It can serve as an organizational tool to help collaborators develop a
comprehensive, coordinated public health approach to addressing children’s mental health.
Putting Concepts into Practice
Implementing the conceptual framework is difficult without concrete examples of what action
steps might look like when applied in different settings. Additionally, groups that are
interested in implementing the framework may need to do preliminary work and planning
activities that precede the steps of the conceptual framework in order to put a comprehensive
approach such as this in place. The final chapter of this document is intended as an
implementation resource, with examples and planning tools to support groups in this work.
A transformation from current approaches to children’s mental health to a public health
approach will require vision and on-going commitment to planning, action and evaluation.
Engaging the public health system, the children’s mental health care system, and partner
systems and organizations to work together in a coordinated and comprehensive approach
will take time and perseverance. One thing that can sustain the effort to change, however, is
the recognition that strengthening mental health enhances the potential for success for all
children and improves the strength of our communities.
EXECUTIVE SUMMARY
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I’m convinced that we can shape a different future for this country as it
relates to mental health…
— DAVID SATCHER, FORMER SURGEON GENERAL OF
THE
UNITED STATES
…mental health is fundamental to overall health and well-being. And that is
why we must ensure that our health system responds as readily to the
needs of children’s mental health as it does to their physical well-being.
One way to ensure that our health system meets children’s mental health

1
A Public Health Approach to Children’s Mental Health:A Conceptual Framework
Introduction
CHAPTER
1
Children who have good health and a strong sense of well-being are more likely to become
adaptable, functioning adults, and will have more tools available to contribute positively to
their communities. Communities and nations are strong and vital when they consist of people
who have the personal resources to take care of their own needs and help those around them.
In this way, good health is a public good: healthy individuals contribute to the health of their
communities and healthy communities support and promote the health of community
members. For a society to be successful and sustainable, therefore, it is best for each baby to
grow up to be healthy and capable.
However, children do not develop optimal health and well-being by default. Many things
strengthen or threaten them as they develop. Some of the most prominent influences include
biological traits, different environments that surround children—physical, social, cultural,
political, and economic, events that occur in their lives, and choices children and their parents
make. These factors all interact to have enormous impact. While some of these factors are
difficult to predict and control, others are shaped by decisions made in communities every day.
In the last century, there are numerous examples in which American society has changed some
factor so as to have a major impact on the health of individual children, as well as the entire
population of children. Universal fluoridated drinking water, child safety seat laws, vaccination
programs, and anti-smoking campaigns have all been effective ways of improving child health
at the societal level. These efforts are examples of what is called a public health approach, one
that focuses on improving the health of populations by promoting positive health and
preventing health threats, as well as providing services for those with specific health problems.
Most American babies today have benefited from public health approaches even before they
are born. Over 95% of all mothers receive some form of prenatal care starting in the first two
trimesters of their pregnancies. During these visits, they are likely to have received at least
some education about diet and nutrition, exercise, immunizations, and the importance of

The thinking behind a public health approach also touches children in other ways. By the age
of six, and sometimes even by age three, every American child gains access to a system of
public education. The United Nations has proclaimed that all children have a fundamental
right to education, in part because of its importance in overcoming inequality and promoting
economic productivity and political stability, and in part because of the impact it has on
children’s health
6
. Unlike health care, however, education is not limited to those who
demonstrate a particular need for it, administered only to those who demonstrate a lack of
intelligence. In fact, education is widely seen as particularly beneficial to those who
demonstrate particular affinity and capacity for intellectual learning.
These examples from the arenas of physical health and intellectual development illustrate
how a population-focused approach emphasizing optimal growth and well-being can be
integrated into American society. However, the examples also provide points of contrast for
the current problem-focused approach to children’s mental health in this country. The field of
children’s mental health care has not yet, broadly adopted a public health approach, nor has
the field of public health focused much attention on children’s mental health. Yet there is
reason to believe that public health efforts that focus on children’s mental health, also
frequently referred to as social and emotional
development or well-being*, can have just as
many societal benefits as those that focus on
physical health.
Some efforts within physical health and
education have a beneficial impact on
children’s mental, social, and emotional
growth. Indeed, some current innovations,
like nurse visitation programs for first-time
mothers or social skills development
programs, provide excellent examples of
effective public health interventions for

Substance Abuse and Mental Health Services Administration,Center
for Mental Health Services (2007).Promotion and Prevention In
Mental Health:Strengthening Parenting and Enhancing Child
Resilience,DHHS Publication No.CMHS-SVP-0175.Rockville,MD.
Text Box
1.1
*The term mental health is used to refer to “social and emotional development,” “social and emotional well-
being,” or “social-emotional learning” in this document.
embraces a focus on helping optimize the mental health of all children, regardless of the
problems they face
†
. By making the mental health of all children important, more children
will become thriving members of society, fewer children will develop mental health problems,
and those who do will be able to receive exceptional care and support.
This public health approach builds on the existing public health and mental health care
systems and promotes integration with other systems and structures that impact children.
This integration of systems and structures is guided by a common understanding and
language, values, guiding principles, and purpose. More specifically, the framework calls for:
1. the children’s mental health care system to incorporate public health concepts in its
approach to children’s mental health,
2. the public health system to place a greater emphasis on children’s mental health, and
3. other child-serving systems and sectors to work as partners in a comprehensive and
coordinated children’s mental health system.
The guiding vision for this effort is that communities, as well as society at large will:
• work to positively shape and strengthen children’s physical, social, cultural, political, and
economic environments in ways that promote optimal mental health and help prevent
mental health problems.
• provide a full continuum of services and supports, from promoting mental health and
preventing problems to treating problems and reclaiming mental health, which help all
children manage environmental, social, and emotional challenges, thrive, and be

Text Box
1.2